Missed Opportunities for Family Planning Counseling at Ministry of Health PHC Centers

Jordan’s fertility rate has been relatively high and stable over the past 10 years. According to the 2007 DHS, the fertility rate is at 3.6 while the Contraceptive Prevalence Rate (CPR) is merely 57%. Reducing the total fertility rate and increasing the CPR are some of the main goals of the Government of Jordan’s National Agenda, and are reflected in the Ministry of Health’s five-year Health Strategy.

In collaboration with the Ministry of Health’s Women and Child Health Directorate (WCHD), the USAID-funded Health Systems Strengthening (HSS) project assisted the Ministry in conducting an Exit Interview survey to identify missed opportunities for family planning (FP) at MOH primary health care (PHC) facilities. The purpose of this survey was to gain a better understanding of the status of FP counseling at PHC facilities, and to identify the major target groups for FP counseling provision. “Missed opportunities” is defined as an opportunity for providing FP information that was missed at a health center (whether within the Maternal and Child Health (MCH) centers or non-MCH units) among non-FP users who are eligible for FP services. It is calculated as the percentage of married women in reproductive age (MWRA) eligible for counseling who have not been provided with any type of FP counseling. The survey provides baseline data on FP missed opportunities at the Ministry of Health, Primary Health Care Centers and, if collected on a regular (annual) basis, would offer the MOH information for better planning and monitoring in the future.

 

 

The Exit Survey was conducted in 36 MOH health centers selected from all 12 health directorates. Using a two-stage cluster sampling, 1,343 married women between the ages of 15 to 49 were selected to be interviewed upon exiting the centers.

Exit Interview for Family Planning Counseling Missed Opportunities at MoH PHC centers-2008 5 Data was collected and categorized into the three regions: North, Center and South. Out of the 36 health centers 35% are located in the North; 48% in the center; and 17% in the South.

 

The survey instrument was administered by the WCHD heads of departments and pilot tested in the field. Pilot testing was conducted in two health centers that were not part of the survey sample, and where a total of 40 clients were interviewed. The survey instrument and the operational manual were modified accordingly.

 

Women and Child Health (MCH) supervisors were trained on the administration of the survey instrument using a detailed operational manual. All data was collected during the period June 1- 15, 2008. MCH supervisors spent at least two days at each health center to ensure that morning and afternoon hours were covered. Depending on the work load of the center, either every other client or one client from every two was selected for an interview, until the target number of clients in each center was reached.

The interview included basic demographic information, questions related to reproductive health and FP methods, in addition to the following six questions related to FP counseling:

1. Were you asked about using a FP method?

2. Did you receive information regarding FP methods?

3. Were you able to discuss various FP methods?

4. Did you see any available FP methods?

5. Were you able to choose a FP method?

6. Was a follow-up planned for you?

 

A client would receive a “complete FP counseling” when she has answered “Yes” to all the above six questions, a “partial FP counseling” when she has answered “Yes” to only some of the questions, and “no FP counseling” when she has answered “No” to all. Missed opportunities for

Exit Interview for Family Planning Counseling Missed Opportunities at MoH PHC centers-2008 6

FP counseling is then calculated as the ratio of non-FP users who received “no FP counseling” during their visit to total non-FP users interviewed.

Results from the Exit surveys reveal a significantly high level of missed opportunities for FP counseling. Specifically, almost 67% of non-FP users in the sample have not been provided with any FP counseling. Almost 71.5% were not asked the single most important question on whether she was using a FP method. Only a very small number – about 9% - of non-FP users have been provided with complete counseling.

One third of all women in the sample do not use any FP method, for a variety of reasons. The majority are either pregnant or in their post-partum period, and compared with FP users in the sample, are on average younger with fewer children. Although FP methods are not needed during pregnancy periods, and pregnancies are unlikely to occur during the early post-partum periods, chances for pregnancy do increase towards the end of the postpartum period. These periods are appropriate times to seize the opportunity to counsel clients on the options for FP methods after delivery.

Opportunities are missed across all levels of services, including general practitioner and vaccination visits. They are also missed regardless of age or family history. Alarmingly, 77% of clients in the sample with more than 7 children have been missed, which suggests lack of attention paid to clients’ characteristics and family size. Clients who have had their last delivery about 3 years ago are almost completely missed. This is worth acknowledging, since it represents the category of clients who would most likely be planning pregnancies in the near future. Finally, the vast majority of non-FP clients who did receive counseling received it from midwives. This suggests a significant deficiency in counseling among general practitioners and nurses.

Improving both demand and access to FP counseling at PHC facilities is essential for better family planning in Jordan. In particular, FP counseling needs to be strengthened in the MCH services and become part of all non-MCH services at the health centers, and be integrated as part

Exit Interview for Family Planning Counseling Missed Opportunities at MoH PHC centers-2008 7